Basic Information
| Provider Information | |||||||||
| NPI: | 1386725406 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VAIL CLINIC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | KEYSTONE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 270596 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800275009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705697478 | ||||||||
| FaxNumber: | 9705697453 | ||||||||
| Practice Location | |||||||||
| Address1: | 1252 COUNTY RD 8 | ||||||||
| Address2: | |||||||||
| City: | KEYSTONE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704686677 | ||||||||
| FaxNumber: | 9705697453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PROPP | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9704797238 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0563 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 33656321 | 05 | CO | MEDICAID |